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Elbow Tendinopathies • Defined As Non-Inflammatory Intratendinous Collagen Degeneration Bernard F

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Elbow Tendinopathies • Defined As Non-Inflammatory Intratendinous Collagen Degeneration Bernard F Tendinosis Elbow Tendinopathies • Defined as non-inflammatory intratendinous collagen degeneration Bernard F. Hearon, M.D. Clinical Assistant Professor, Department of Surgery • Angiofibroblastic hyperplasia - University of Kansas School of Medicine - Wichita hypertrophic fibroblasts, vascular April 23, 2019 hyperplasia, disorganized collagen • Areas of focal necrosis, calcification • No acute inflammatory cells Elbow Tendinopathies Distal Biceps Potential Mechanisms of Rupture: Arterial Supply, Mechanical Impingement. Seiler Tendinosis vs Tendinitis et al., JSES 1995; 4: 149-56. • “Tendinosis” implies an intrinsic degenerative • Proximal one-third supplied by brachial artery condition, determines therapeutic goals, sets • Distal one-third from posterior interosseous reasonable outcome expectations recurrent artery • “Tendinitis” implies an inflammatory condition, • 2-cm middle-third is a hypovascular zone where is misleading, allows misguided treatment & blood supply is from paratenon unreasonable expectations • Radioulnar space for tendon is 48% less in pronation than in supination • Basic Science study (Emory University) Elbow Tendinopathies Elbow Tendinopathies Read File Distal Biceps Ruptures Bilateral ruptures of the distal biceps brachii tendon Epidemiology Schneider et al., JSES 2009; 18: 804-07. • 25 pts, non-simultaneous bilateral biceps ruptures • Male mesomorphs (rare in females) • All pts male, average age 50 (range 28 to 76) Age range 30-60 years (mean age 47) • • Mean time between ruptures 2.7 yrs (0.5 to 6.3) • Dominant extremity (86%) • Pts found to have higher rate of nicotine (50%) • Incidence 1.2 ruptures / 100K / year (rare) and anabolic steroid use (20%) • Smokers 7.5 times greater risk • Therapeutic Level IV study (Fondren, Houston) Elbow Tendinopathies Elbow Tendinopathies Read File Distal biceps tendon insertion: An anatomic study Distal Biceps Anatomy Hutchinson et al., JSES 2008; 17: 342-46. • 20 cadavers dissected to define biceps footprint • Short head and long head • Insertion at posteroulnar to middle aspect of the • Musculocutaneous innervation radial tuberosity in all specimens • Elbow flexor, forearm supinator • Shape of insertion is semilunar or oval • Radial tuberosity insertion • Reinsertion should be aimed at the posteroulnar • Bicipital aponeurosis (lacertus fibrosis) aspect of the radial tuberosity • Basic Science study (UTHSC - San Antonio) Elbow Tendinopathies Elbow Tendinopathies Read File Distal Biceps Tendon Anatomy: A Bicipital Aponeurosis Cadaveric Study (Lacertus Fibrosis) Eames et al., JBJS 2007; 89A: 1044-49. Arises from short head biceps • In 10/17 cadavers, long & short heads had • distinct insertions on radial tuberosity • Envelops volar forearm muscles • Short head inserted distally, better flexor • Statically, stabilizes the biceps • Long head inserted proximally, better supinator • Dynamically, flexor-pronator contraction pulls biceps medially • Bicipital aponeurosis may be stabilizer • Should lacertus be preserved or • Basic Science study (Australia) released during biceps repair? Elbow Tendinopathies Read File Elbow Tendinopathies Clinical History Clinical Exam Absence palpable tendon (hook test) • Sudden forced extension on flexed elbow • Bicipital crease interval (bicipital crease ratio) • Eccentric contraction of the biceps • Weakness on resisted forearm supination • Tearing sensation anterior elbow, audible pop • Biceps squeeze test • Abnormal biceps contour, reverse “Popeye” • Passive forearm pronation test • Weakness elbow flexion, forearm supination • • Bicipital aponeurosis flex test Elbow Tendinopathies Elbow Tendinopathies Diagnostics Best MRI for Distal Biceps FABS Technique • Radiographs may show spurs, avulsion fracture • Ultrasound may confirm Flexed elbow complete rupture Abducted shoulder • MRI most helpful for partial distal biceps tear Supinated forearm Elbow Tendinopathies Elbow Tendinopathies Nonoperative Treatment of Distal Biceps Tendon Ruptures Freeman et al., JBJS 2009; 91-A: 2329-34. JSES 2019 - Therapeutic Level IV - Univ Pittsburgh • 20 cases (18 pts, 16 males), 50 yrs (range 35-74) • 14 pts rx nonoperatively matched to 18 uninjured • 7 dominant arm, 9 nondominant arm, 2 both • Assessed w/DASH, SANE, torque dynamometer • Mean supination strength 74% +/- 33%, mean • flexion strength 88% +/- 16% • Outcomes - clinically meaningful impairment • Overall satisfactory outcomes, one unsatisfactory • Supination power decreased by 47% • Therapeutic Level IV study (Erie, PA) • Useful in preoperative patient counseling Elbow Tendinopathies Read File Elbow Tendinopathies Read File Classic Two-Incision Technique Evolution of Single Anterior Morrey, 1985 Incision Repair Anterior incision, deliver tendon, whip stitch Date Author Technique • 1996 Lintner Suture anchors • Advance large clamp between radius & ulna 2000 Bain Endobutton • Posterior approach between EDC and ECU 2005 Mazzocca Endobutton, screw • Expose and prepare radial tuberosity, deliver 2008 Mazzocca Cortical button, screw sutures through drill holes and tie 2011 Siebenlist Two IM cortical buttons 2013 Tanner Direct suture repair Elbow Tendinopathies Elbow Tendinopathies Does immediate elbow mobilization after Cortical Button distal biceps tendon repair carry risk? Tension-Slide Method Smith et al., JSES 2016; 25: 810-15. • 22 distal biceps repairs w/cortical button technique Dx complete tear is clinical • • Pts encouraged to begin early elbow ROM on DOS MRI unnecessary • • All male pts, mean age 40.6 yrs, mean F/U 16.6 mo Single incision, cortical button w/o screw • • No pt complaints, wound dehiscence, repair failure Tie down with knot pusher • • 33% experienced transient neurapraxia • Therapeutic Level IV study (UK) Elbow Tendinopathies Elbow Tendinopathies Read File Single vs Double-Incision Technique - Distal Biceps Tendon Repair Grewal et al., JBJS 2012; 94-A: 1166-74. • JSES 2017 - Level III Case-Control Rx - Canada • Single incision, two suture anchors (n = 47) • 16 delayed repairs (> 21d) matched w/acutes (1:3) • Double incision, transosseous drill holes (n = 44) • Time to surgery - 37 ± 12 days vs 10 ± 6 days • Elbow flexion strength 10% better w/two incisions • Complications - 63% (paresthesias) vs 29% (2 re-tears) • LABC neurapraxia 40% pts w/one incision • No difference in outcomes - DASH, PREE, ASES • Four tendon re-ruptures due to noncompliance • Therapeutic Level I study (Canada) Elbow Tendinopathies Read File Elbow Tendinopathies Read File Distal Biceps Partial Tears Distal Biceps Anatomy • Anterior elbow pain radiating to biceps often after injury event (lifting, forced extension) Tendon may be bifurcated (13%) • Tender distal biceps, weak resisted supination • • MRI often diagnostic but may be equivocal • Partial tear may be short head only • Nonsurgical rx including PT does not help • Short head tear may extend to long head • Surgical options are in situ repair vs take-down and re-attachment Elbow Tendinopathies Elbow Tendinopathies Surgical Treatment of Partial Distal Biceps Tendon Ruptures Frazier et al., JHS 2010; 35-A: 1111-14. • JSES 2018 - Level IV Rx - Thomas Jefferson Univ • Retrospective review 17 pts w/partial tears • 74 pts w/partial tears, 13 immediate surgery • 14/17 failed nonoperative treatment • Nonoperative - 34 of 61 (56%) had late surgery • One re-rupture, two LABC neurapraxia • Satisfaction same for early or late operation • Elbow flexion 10% stronger, supination 10% • High-demand occupations did better w/surgery weaker than contralateral side • MRI-dx tear > 50% predicted need for surgery • Therapeutic Level IV study (Univ Pittsburgh) Elbow Tendinopathies Read File Tendinopathies Reading List Partial Tears of the Distal Biceps Tendon: Distal biceps tendon tears in women A Systematic Review of Surgical Outcomes Jockel et al., JSES 2010; 19: 645-50. Behun et al., JHS 2016; 41-A: e175-e189. • 15 cases (13 pts), mean age 63 yrs (range 48-79) • Meta-analysis 19 studies, 86 partial tears repaired • 7 single injury, 8 insidious onset, 6 cystic mass • 65 pts had failed trial non-surgical treatment • 14 partial tears, all did well with surgical repair • Surgical repair yielded 94% satisfactory outcome • Distal biceps tears rarely occur in women • LABC paresthesia most common (17%) complication • Age is older than men, no trauma, associated • Therapeutic Level IV study (Western Michigan Univ) with cyst, mostly partial tears • Therapeutic Level IV study (Tufts University) Elbow Tendinopathies Read File Elbow Tendinopathies Read File Surgical Complications Chronic Tears • LABC neurapraxia • Primary repair in extreme flexion • PIN palsy • Reconstruction with Achilles tendon allograft • Heterotopic ossification • Lacertus fibrosis local autograft • Radioulnar synostosis • Tenodesis to brachialis • Tendon re-rupture • CRPS / RSD • Wound infection Elbow Tendinopathies Elbow Tendinopathies Drilling Angle & PIN Safety • JSES 2018 - Level III Treatment - Carolina Med Ctr • Position full supination • CPT code 24342, January 2005 - April 2017 • Drill perpendicular to long axis of radius • Single incision - 652 cases, 2-incision - 318 cases • Aim 0 to 30 degrees ulnarly to improve margin of safety • 7.5% major complication, 4.5% re-operation • Basic Science study (Naval Med Ctr, San Diego) • Single incision - increased LABC or SRN neuritis • Two-incision - increased radioulnar synostosis Elbow Tendinopathies Elbow Tendinopathies Read File Review of 150 Acute Triceps Ruptures Diagnosis Mirzayan et al., 2014 ASES Meeting Eccentric load, resisted elbow extension • Average age 49 years (range
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